Tobacco Use Among High School Students -- United States, 1997

Tobacco use is the single leading preventable cause of death
in the
United States (1). Approximately 80% of tobacco use occurs for the
first time among youth aged less than 18 years (2), and the
prevalence of cigarette smoking among adolescents increased during
the early 1990s (3). To determine prevalence rates of cigarette,
smokeless tobacco (chewing tobacco or snuff), and cigar use for
U.S. high school students, CDC analyzed data from the 1997 Youth
Risk Behavior Survey (YRBS). This report summarizes the results of
the analysis, which indicate that the prevalence of current
cigarette smoking among U.S. high school students increased from
27.5% in 1991 to 36.4% in 1997 and that, in 1997, 42.7% of students
used cigarettes, smokeless tobacco, or cigars during the 30 days
preceding the survey.

YRBS, a component of CDC's Youth Risk Behavior Surveillance
System
(4), biennially measures the prevalence of priority health-risk
behaviors among youth through representative national, state, and
local surveys. The 1997 national YRBS used a three-stage cluster
sample design to obtain a representative sample of 16,262 students
in grades 9-12 in the 50 states and the District of Columbia. The
school response rate was 79.1%, the student response rate was
87.2%, and the overall response rate was 69.0%. Data were weighted
to provide national estimates, and SUDAAN (R) (Software for
the Statistical Analysis of Correlated Data) was used to calculate
standard errors for determining 95% confidence intervals. *

Students completed a self-administered questionnaire that
included
questions about cigarette, smokeless tobacco, and cigar use.
Lifetime cigarette smokers were defined as students who had ever
smoked cigarettes, even one or two puffs. Current cigarette,
smokeless tobacco, and cigar users were defined as students who
reported product use on greater than or equal to 1 of the 30 days
preceding the survey. Frequent cigarette use was defined as smoking
cigarettes on greater than or equal to 20 of the 30 days preceding
the survey. Any current tobacco use was defined as use of
cigarettes, smokeless tobacco, or cigars on greater than or equal
to 1 of the 30 days preceding the survey. Data are presented only
for non-Hispanic black, non-Hispanic white, and Hispanic students
because the numbers of students from other racial/ethnic groups
were too small for meaningful analysis.

Prevalence of Cigarette Use

The overall prevalences of lifetime, current, and frequent
cigarette use were 70.2%, 36.4%, and 16.7%, respectively
(Table_1).
The prevalence of lifetime cigarette smoking was higher among
Hispanic male students (76.9%) than among white male students
(70.4%). The prevalence of current cigarette smoking was higher
among white students (39.7%) than Hispanic (34.0%) and black
(22.7%) students, and Hispanic students (34.0%) were more likely to
report current cigarette smoking than black students (22.7%). Among
males, the prevalence of current cigarette smoking was higher among
white students (39.6%) than black students (28.2%). Among females,
the prevalence of current cigarette smoking was higher among white
students (39.9%) than Hispanic (32.3%) and black (17.4%) students,
and Hispanic female students (32.3%) were more likely to report
current cigarette smoking than black female students (17.4%). Among
black students, males (28.2%) were more likely than females (17.4%)
to report current cigarette smoking.

The prevalence of frequent cigarette smoking was higher among
white
students (19.9%) than among Hispanic (10.9%) and black (7.2%)
students. Among males, the prevalence of frequent cigarette smoking
was higher among white students (19.8%) than black students
(10.1%). Among females, the prevalence of frequent cigarette
smoking was higher among white students (20.1%) than Hispanic
(8.1%) and black (4.3%) students. Among black students, males
(10.1%) were more likely than females (4.3%) to report frequent
cigarette smoking.

Trend analyses of current cigarette smoking found
significantly
increasing trends overall and among all racial/ethnic subgroups (p
less

than 0.001). The overall prevalence of current cigarette smoking
increased
from 27.5% in 1991 to 36.4% in 1997. Among white students, current
cigarette smoking increased from 30.9% in 1991 to 39.7% in 1997.
Among
black students, current cigarette smoking increased from 12.6% in
1991 to
22.7% in 1997. Among Hispanic students, current cigarette smoking
increased
from 25.3% in 1991 to 34.0% in 1997.

Prevalence of Smokeless Tobacco Use

The overall prevalence of current smokeless tobacco use was
9.3% (Table_1). The prevalence of current smokeless tobacco use
was
higher among male students (15.8%) than female students (1.5%) and
among white students (12.2%) than black (2.2%) and Hispanic (5.1%)
students. White male students (20.6%) were more likely than any
other subgroup to report current smokeless tobacco use; Hispanic
male students (8.4%) were more likely than black male students
(3.2%) to report this behavior. Among Hispanic students, males
(8.4%) were more likely than females (1.2%) to report current
smokeless tobacco use.

Prevalence of Cigar Use

The overall prevalence of current cigar use was 22.0%
(Table_1).
Male students (31.2%) were more likely to use cigars than
female students (10.8%). This difference held within each
racial/ethnic subgroup. Ninth-grade students (17.3%) were less
likely than 11th-grade students (24.2%) to use cigars.

Prevalence of Any Current Tobacco Use

The overall prevalence of any current tobacco use was 42.7%
(Table_1). Male students (48.2%) were more likely to report any
current tobacco use than female students (36.0%), and this
difference held within each racial/ethnic subgroup. The prevalence
of any current tobacco use was higher among white students (46.8%)
than Hispanic (36.8%) and black (29.4%) students. These differences
held for both male and female students. The prevalence of any
current tobacco use was higher among Hispanic students (36.8%) than
black students (29.4%) overall and among female students (31.4% of
Hispanic females and 21.5% of black females).

Reported by: Office on Smoking and Health, and Div of Adolescent
and School Health, National Center for Chronic Disease Prevention
and Health Promotion, CDC.

Editorial Note

Editorial Note: This report is the first to include cigarette,
smokeless tobacco, and cigar use in a measure of current tobacco
use and the first to report on past-month cigar use among a
nationally representative sample of high school students. The
increasing prevalence of cigarette smoking since 1991, the high
rate of smokeless tobacco and cigar use, and the high rate of any
tobacco use suggest that a major proportion of U.S. youth already
have or are at risk for nicotine addiction (5,6) and the subsequent
health problems caused by tobacco use (2,6).

In 1997, the prevalence of current cigarette smoking was 32%
higher than in 1991; current cigarette smoking increased 80% among
black students, 34% among Hispanic students, and 28% among white
students. The reasons for the large differences in overall
prevalence of current cigarette smoking and the increases in
cigarette smoking among students in all the racial/ethnic groups
are unclear and require further investigation. CDC is conducting
research to help explain these differences and the reasons for
continued increases in tobacco use among all youth.

The findings in this report are subject to at least two
limitations. First, these data apply only to youth who attend high
school and, therefore, are not representative of all persons in
this age group. In 1996, only 6% of persons aged 16-17 years were
not enrolled in a high school program and had not completed high
school (7). Second, the measure of any current tobacco use
described in this report might be an underestimate, because it does
not include measures of pipe and "roll-your-own" tobacco smoking.

In 1994, CDC recommended that school-based tobacco-use
prevention programs begin in elementary school and continue through
12th grade, with intensive instruction for students in grades six
through eight (i.e., up to 10 smoking-focused sessions each year)
(8). Data from the 1994 School Health Policies and Programs Study
indicated that only 55% of middle/junior high and 47% of senior
high school health education teachers taught tobacco-use prevention
as a major topic (9). Of these teachers, 43% of middle/junior high
and 42% of senior high school teachers taught only one or two
classes on the topic. Additional research findings indicate that
school-based tobacco-use prevention programs are most effective
when supported by communitywide programs that involve parents,
peers, mass media, and community organizations (2).

Tobacco-use prevention activities should be designed to
prevent the use of all tobacco products. Such activities should
include increasing tobacco prices, reducing access (e.g., by
implementing and adequately enforcing minors' access restrictions),
reducing the appeal of tobacco products (e.g., by restricting
advertising and promotion), and conducting youth-oriented mass
media campaigns and school-based tobacco-use prevention programs
(2,10). Establishing health-oriented social norms (e.g., by
increasing provision of smoke-free indoor air and decreasing
modeling of tobacco use by parents, teachers, and celebrities) and
increasing support and involvement from parents and schools also
will contribute to prevention (2).

References

McGinnis JM, Foege WH. Actual causes of death in the United
States.
JAMA 1993;270:2207-12.

US Department of Health and Human Services. Preventing tobacco
use
among young people: a report of the Surgeon General. Atlanta:
US
Department of Health and Human Services, Public Health Service,
CDC,
1994.

Everett SA, Husten CG, Warren CW, Crossett L, Sharp D. Trends
in
tobacco use among high school students in the United States,
1991-1995.
J Sch Health (in press).

Food and Drug Administration. Regulations restricting the sale
and
distribution of cigarettes and smokeless tobacco to children
and
adolescents; final rule. Federal Register 1996;61: 44395-618.

Differences between prevalence estimates were considered
statistically significant if the 95% confidence intervals did not
overlap. Use of trade names and commercial sources is for
identification only and does not imply endorsement by CDC and the
U.S. Department of Health and Human Services.

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